Trade Agreements and Non-communicable Diseases in the Pacific Islands

David Legge1, Deborah Gleeson1, Wendy Snowdon2 and Anne Marie Thow3 1. School of Public Health and Human Biosciences, La Trobe University 2. Pacific Research Centre for the Prevention of Obesity and Non-Communicable Diseases 3. Menzies Centre for Health Policy, The University of Sydney

First prepared August 2011 Revised January 2013

Introduction There are several sets of trade negotiations in place, under way or foreshadowed which do or will powerfully shape how the Pacific Island peoples are positioned within the evolving global economy and which will strongly influence the social determinants of health, including the determinants of non-communicable diseases. The Pacific island countries are already involved in global trade, importing goods from all over the world and exporting globally as well. There is an international trend towards increasing numbers of bilateral and regional trade agreements and the Pacific island countries are no exception to this, becoming involved in an expanding web of trade agreements with many other countries. Trade agreements can hold significant benefits such as increasing exports to foreign markets, attracting foreign investment and reducing the price of imported goods. These benefits can lead to higher living standards and better health. However, trade agreements can also present risks to health unless the possible health implications are taken into account in their design and negotiation. This booklet was prepared for the Pacific NCD Forum in August 2011. It introduces the trade agreements that could have an impact on non-communicable diseases in the Pacific islands, reviews some of the common elements of trade agreements and how they affect NCDs and makes some suggestions for how the health sector can contribute to healthier trade policy. Inter-related trade negotiations in the Pacific Islands Forum

Key: , EPA Economic Partnership Agreement, MSG Melanesian Spearhead Group Free Trade Agreement, PACER Pacific Agreement on Closer Economic Relations, PATCRA Papua New Guinea – Australia Trade and Commercial Relations Agreement, PICTA Pacific Island Countries Trade Agreement, SPARTECA South Pacific Regional Trade and Economic Cooperation Agreement, WTO World Trade Organisation. Diagram adapted from Oxfam Australia and Oxfam New Zealand, 2009. PACER Plus and its Alternatives: Which way forward for trade and development in the Pacific?

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The principles and logic of trade agreements Some of the core principles and philosophies underlying trade agreements include ‘trade liberalization’, ‘national treatment’ and ‘most favoured nation treatment’ [1]. The logic of trade liberalization is all about encouraging the flow of goods and services between countries by eliminating barriers to trade. The theory is that trade liberalization encourages economic development, which according to economic theory, should also lead to social development and greater wealth. However, when developing countries open up their markets and liberalize their trade with developed nations, they often don’t see the promised benefits. In the extreme case, the consequences could be a flood of cheap imports but little in the way of enhanced export opportunities. Extensive support is needed to ensure that they can make use of the freer trade [ 2]. Additionally, when economic development does occur, the benefits are not always equally shared [3]. National treatment means that a country must treat the goods and services from other countries no less favorably than it treats domestically produced goods and services. This means extra taxes and bureaucratic procedures can’t be applied solely to foreign goods and services. Most favoured nation treatment means that countries cannot discriminate between their trading partners, and treat goods and services from some partners less favourably than others. For example, tariffs (import taxes) cannot be lowered just for one trading partner while imports from other countries remain subject to higher tariffs. All trading partners must be treated as favourably as the most favoured nation. However, there are some exemptions to this rule, such as in the case of free trade agreements and customs unions.

How trade agreements work When countries sign up for membership in trade agreements, the rules for that agreement are discussed and committed to between the members. For smaller and new agreements like the Melanesian Spearhead Group (MSG), it is the member countries who agree upon the rules among themselves, with each country considering the advantages to their own country and to the group as a whole. When a country seeks membership of the World Trade Organization (WTO), discussions centre on what that potential member should agree to in order to become a member. The WTO has some agreements which everyone must sign up to and some agreements where new members can make choices about what they agree to. Even in those agreements which all countries must sign up to there is some scope for variation in the specific commitments undertaken. Least Developed Countries (LDC) are allowed certain concessions such as delaying reductions in subsidies for farmers or phased reduction of import duties. This negotiation phase is obviously a very important process. If the negotiating team is successful they can obtain an agreement which has more benefits and fewer disadvantages for their country. It is also at this stage that potential health impacts need to be considered.

Trade agreements and developing countries While developing countries are entitled to special and differential treatment in WTO agreements, in practice, developing countries including LDCs often sign up to deeper commitments than the WTO requires when they enter bilateral or regional trade agreements with developed

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countries. This highlights the importance of careful consideration of trade agreements and their requirements before sign-up – and strong negotiation. So why do Pacific island countries enter into trade agreements? Reasons that are often given include gaining access to foreign markets for their exports, attracting foreign investment, and facilitating administrative reforms. Developing countries, however, are often at a significant disadvantage when they enter into trade negotiations. It is very hard to predict some of the longer term consequences of particular provisions. When small countries with relatively few trade negotiators are negotiating with large countries with much more experience and many more trade experts it can be hard to give proper weight to all of the possible social and health impacts.

Policy space and trade agreements Policy space refers to the ‘freedom, scope and mechanisms that governments have to choose, design and implement public policies to fulfill their aims’ [4]. Because trade agreements involve rules about how governments can regulate markets, they can constrain policy space for governments to make policies on many important public health issues, such as food labeling and tobacco control. However careful design of trade agreements can preserve policy space for governments to make policies and laws in relation to important public health issues. This emphasizes the importance of taking health into consideration in trade agreements.

Some common elements of trade agreements and their potential impact on health It is customary in the world of trade regulation to use the term ‘chapters’ to refer to the different parts of a trade agreement. These commonly deal separately with topics like: Trade in goods Trade in services Regulation of intellectual property rights (TRIPS and TRIPS Plus provisions) Investment protections such as expropriation and investor state dispute settlement procedures Government procurement Non tariff barriers to trade (e.g. quotas, import/export licenses, administrative barriers) Sanitary and phytosanitary measures The table on the next page outlines some of the chapters and provisions that are commonly included in trade agreements and the opportunities for and risks to health1 that they can present.

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While this document focuses on health, trade also has an impact on other sectors (e.g. employment, agriculture, education) and issues (e.g. human rights, environment).

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Trade Provisions – Opportunities and Risks for Population Health Chapter/provision Trade in goods – reducing tariffs (import taxes) and other barriers to trade such as import quotas

Possible benefits for population health Reduced tariffs lead to cheaper imports of a range of goods including fuel, foods, farming equipment etc, which can lead to higher living standards and better health, for example, through improving dietary diversity. Reduced tariffs and improved access to export markets can lead to increased economic activity with flow on effects in terms of local investment, employment and living standards.

Trade in services – opening up markets to foreign investment

Opening up health insurance and health care to foreign companies might lead to more investment in new facilities and bring in new technologies.

Labour mobility

Remittances from migrant workers can contribute to employment, family incomes and economic development.

Possible risks for population health Reduced government revenue from tariffs can mean less money to spend on health services and can also affect other social determinants of health such as education, employment and transport. Reduced revenue from tariffs may necessitate increases in indirect taxes which may impact on living standards for low income families Reducing import taxes can lower the cost of unhealthy products such as fatty meats, soft drinks, alcohol and tobacco. Commitments in trade agreements can make it more difficult for governments to introduce policies and laws to control the supply and price of unhealthy products. Making commitments in trade agreements regarding health insurance or health care would restrict government policy space in regulating health care for quality, access and efficiency. Market opening may lead to a diversion of resources to private healthcare providers, with implications for access to care. International cooperation in the delivery of services such as health care can still be encouraged without making binding commitments in trade agreements. Labour mobility provisions can exacerbate the loss of skilled health workers to other countries.

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Chapter/provision Protection of intellectual property rights, including in particular, the WTO’s Trade Related Intellectual Property Rights Agreement (TRIPS)

Possible benefits for population health The rationale for intellectual property provisions is to incentivize investment by ensuring that companies investing heavily in research and development (such as some pharmaceutical companies) can recoup their investment through the patent mechanism

Investment protection for foreign investors (includes expropriation and investor-state dispute settlement provisions)

Investor protection might encourage investment in countries by companies who might not otherwise invest. Such investment might contribute in various ways to economic development which might translate into better health.

Possible risks for population health The TRIPS Agreement is part of the single undertaking binding all WTO members. TRIPS requires countries to give pharmaceutical companies 20-year patents for new medicines. There are some flexibilities and safeguards available within TRIPS which are not always available in ‘TRIPS Plus’ agreements. For example, TRIPS allows countries considerable discretion in writing national patent law, including high standards for patenting and the ability to allow the generic manufacture and the importation of patented drugs in certain circumstances. Many developing countries are now being asked to agree to ‘TRIPS Plus’ measures in trade agreements which prevent developing countries from using flexibilities available to them under TRIPS. Such measures are likely to increase the cost of some medicines (e.g. by restricting the use of generic drugs) [5]. ‘Investment protection’ provisions allow foreign investors to sue governments for compensation. This means that the policy space for governments to introduce public health legislation such as tobacco control measures and compulsory licensing of pharmaceuticals can be severely constrained. While this sort of legal action can be contested on health grounds, there have been many non-health cases where companies have won claims made under these sorts of provisions and governments have been forced to make large payouts. Sometimes even the threat of legal action can make governments reconsider whether to introduce public health policies that might attract legal action by foreign companies. The suite of agreements negotiated under the WTO does not include investor protection of this type. However many bilateral and regional trade and investment agreements do include such provisions. 6

Chapter/provision Government procurement – the supply of goods and services to governments

Possible benefits for population health Opening up government procurement to international competition might promote lower prices, greater efficiency, higher quality and more integrity.

Sanitary and phytosanitary measures and technical barriers to trade (food safety and animal and plant health standards)

Restrictions on countries imposing sanitary and phytosanitary standards higher than the basic international standard are justified in terms of preventing the use of such standards as covert trade barriers. Exporters benefit from countries not being able to erect such barriers to imports.

Possible risks for population health Domestic supply of goods and services to government often makes up a significant part of small island states’ economies. Opening up government procurement to foreign competition with National Treatment provisions (see above) may reduce domestic employment and economic development. Sanitary and phytosanitary (SPS) measures mean that health regulations cannot be applied differently to foreign goods and services (compared with domestically produced) and, in some circumstances, cannot be more stringent than relevant international standards (in the case of food, this is the Codex Alimentarius, which is focused on food safety). The SPS Agreement requires SPS measures to be based on a risk assessment. There are also general provisions requiring that measures be based on scientific principles and not maintained without sufficient scientific evidence. These standards are complex and particularly difficult for developing countries to comply with in low resource settings.

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Current trade negotiations in the Pacific island countries PICTA The Pacific Island Countries Trade Agreement (PICTA) is a regional free trade agreement between members of the Pacific Island Forum Countries (excluding Australia and New Zealand) that commits the member countries to phasing out barriers to trade, including tariffs and non-tariff barriers [6]. This affects trade between the member countries, for example, Papua New Guinea would lower its barriers to trade for goods coming from the Solomon Islands. It came into force in 2003 and until August 2012, covered trade in goods, but was recently expanded to include trade in services (including hospitals and other health services) and negotiations are underway to include the movement of workers between countries. Tobacco and alcohol were excluded from PICTA due (at least in part) to concerns that reducing tariffs on alcohol and tobacco could reduce the cost and increase consumption of these products. A case was put forward during the development of PICTA for these to be excluded [7], and it was agreed to by the negotiators. In August 2012, the PICTA Trade in Services (TIS) Protocol was opened for signature. The Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Republic of the Marshall Islands, Nauru, Niue, Republic of Palau, Papua New Guinea, Samoa, Solomon Islands, Tonga, Tuvalu and Vanuatu are all entitled to accede. To date it has been initialed by the Cook Islands, FSM, Kiribati, Republic of the Marshall Islands, Samoa, Solomon Islands, Tonga, Tuvalu and Vanuatu. This protocol covers many sectors, and several countries have made commitments regarding health related and social services. The extension of PICTA to include trade in services is important because it will pave the way for trade in services negotiations with the European Union (in the EPA) and with Australia and New Zealand (in PACER Plus). A social impact assessment of liberalizing trade in services and temporary labour mobility among Forum Island Countries was commissioned by the Pacific Islands Forum Secretariat, but the report does not appear to be publicly available.

EPAs Economic Partnership Agreements (EPAs) are currently being negotiated between the European Union (EU) and the African, Caribbean and Pacific (ACP) Group of States. The EPAs are described as trade and development agreements as they are linked with EU development assistance arrangements (under the 2000 Cotonou Agreement). The previous arrangements providing for goods from the ACP countries to have preferential access to the EU market (the Lomé Convention) had been declared WTO non-compliant following a complaint from Latin America. In June 2002 the EU Council authorized EU trade officials to negotiate regional EPAs which would provide for "substantially all trade" in goods (at least 80%) plus services, investment protection and trade-related rules (including rules of origin, intellectual property, government procurement, regulatory standards, etc). It was originally intended that EPAs would be concluded on a regional basis (five African regions and one each for Caribbean and Pacific). Thus it was intended that the EU would enter into a single agreement with all of the Pacific ACP states. However, because this agreement could not be concluded by the deadline (Dec 31 2007) the EU elected to proceed with ‘interim EPAs’ with individual countries. In 2007 Fiji and PNG both agreed to sign interim EPAs (dealing only with on trade in goods but with the expectation of further negotiations) in order to gain access to European

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markets for their tuna and sugar exports [8]. PNG ratified their iEPA in May 2011; Fiji has not ratified its iEPA. All fourteen Pacific Island Forum Countries are continuing to negotiate with the EU. One of the most contentious issues for the Pacific Island Countries concerns fisheries. The PICs would like to strengthen their involvement in fish processing including wider procurement and moving up the value chain. The EU has a large (and heavily subsidized) fishing fleet of its own to worry about. The European fishing industry is opposed to the EU subsidizing Pacific producers to compete within the European market. Other distant fishing nations, especially China and Japan, are also invested heavily in Pacific fishing and processing. The EPA between the EU and the Caribbean nations, which sets a precedent for the Pacific EPA, contains stronger provisions than those required by the WTO in some chapters and restricts the ability of governments to regulate services, investments and labour mobility. Most of the Caribbean ACP countries have not yet ratified the EPA. None of the regional EPAs for the African regions have been concluded. Some countries have initialed iEPAs but many of these have not been ratified. There is some skepticism regarding EPAs in Africa; this scepticism appears to be widening. The EU has issued an ultimatum to the effect that countries which have not entered into EPAs by the end of 2013 will lose preferential access to the EU market. This will not affect ‘Least Developed Countries’ which already have guaranteed access to the EU market (includes Samoa, Timor-Leste, Tuvalu, Solomon Islands, Vanuatu).

PACER and PACER Plus PACER, the Pacific Agreement on Closer Economic Relations, which came into force in 2002, was a ‘framework agreement’ for trade and economic integration between PICTA members and Australia and New Zealand [10]. Its purpose was to prepare for future trade cooperation in the region. In 2009, negotiations began towards a regional trade agreement between the Pacific islands, Australia and New Zealand, called PACER Plus. Negotiations are still at a relatively early stage, with the fifth round of negotiations held in November 2012 and an inter-sessional meeting planned for April 2013. It is unclear at this stage to what extent PACER Plus will be a conventional free trade agreement or whether it will be framed more as a development agreement. Priority issues for the Pacific island countries seem to be labour mobility and development assistance (for which an ‘early harvest’ is sought), with other issues under discussion including rules of origin, customs procedures, sanitary and phytosanitary measures, and technical barriers to trade. Services and investment are also on the agenda for future discussion [11]. The main potential benefits are likely to be improved access to Australian and New Zealand markets and expansion of seasonal worker opportunities in Australia and New Zealand. The agreement would also increase access for Australian and New Zealand goods and services into the region. There are a number of potential risks to health, depending on what is included in PACER Plus [12]. These potential risks include:

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Reduced government spending on health care, if government revenue is severely affected by tariff cuts2;

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Lower prices for all imported goods from Australia and New Zealand including junk foods, alcohol and tobacco3;

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Reduced ability for government to regulate to protect health;

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Increased cost of medicines (if TRIPS Plus provisions4 are included),

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Further loss of health workers to Australia and New Zealand;

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Risks to the social determinants of health (income, education, employment, transport) due to lower government revenue from reduced import tax revenues and reduced local manufacturing.

WTO Accession PNG, Fiji and the Solomon Islands are founding members of the World Trade Organization (WTO). Tonga joined in 2007, and Vanuatu and Samoa both ratified their accession packages in 2012 (in May and August respectively). Low income countries often see WTO membership as an important step in gaining access to foreign markets for their exports, attracting foreign investment and reforming their own economies and policies [13]. Actually the costs associated with WTO accession can be very high for low income countries. Evidence that WTO accession helps such countries achieve their development objectives is weak and contradictory [13]. Countries that join WTO now are required to make far more changes to their trade policies than countries which joined earlier (this is known as WTO+) [13]. Least Developed Countries (LDCs) are able to take advantage of some flexibilities, but not all do. Nepal, Cambodia and Tonga are examples of low income countries that were forced to make WTO+ commitments. Nepal and Cambodia lost the ability to protect their vulnerable agricultural sectors using tariffs and subsidies [14]. It has been claimed that Tonga made commitments to reduce tariffs to almost record lows, and agreed to commitments that may limit its ability to regulate services, including health services [15]. Vanuatu agreed to fully apply all WTO provisions immediately following accession except for intellectual property rights and the publication of trade information, which were subject to transitional periods [16]. Concerns that have been expressed regarding Vanuatu’s WTO accession package include: commitments to substantial reductions in tariffs, extensive commitments to open up services to foreign investment; restrictions to Vanuatu’s ability to introduce new regulations; and stringent requirements for intellectual property which are likely to increase the cost and reduce the

2 A 2007 report by Nathan Associates Inc. to the Pacific Island Forum Secretariat entitled ‘Pacific Regional Trade and Economic Cooperation: Joint Baseline and Gap Analysis’ predicted that PACER-Plus tariff reductions will erode the tax base significantly in countries which are reliant on tariffs for tax revenues. Fiji, PNG, Samoa and Vanuatu could lose more than $10 million per year and the Cook Islands, Kiribati, Samoa, Tonga and Vanuatu could lose more than 10% of their total revenue. 3 Excise taxes may in some cases be used to offset tariff reductions, however these taxes may have higher transaction costs and can be more difficult to enforce [12]. 4 TRIPS Plus provisions can extend the duration of patents, allow more medicines to be patented, allow patents to be granted for less reason, make it more difficult for generics manufacturers to use clinical trial data to register their products, prevent unwarranted patent applications from being challenged before the patent is granted, and prevent countries from importing medicines from other countries where they are cheaper or granting compulsory licenses to generics manufacturers.

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availability of medicines [17]. It has been suggested that this deal could severely constrain the ‘policy space’ of Vanuatu’s government to protect health. Samoa also agreed to fully apply most WTO provisions immediately (with a few exceptions) [18]. As a condition of WTO accession, Samoa agreed to remove its ban on the importation and domestic distribution of turkey tails (a high fat meat product) within twelve months, and replace the ban with less trade-restrictive measures including a domestic ban on the sale of these products and a 300% import duty. During the two year period following accession, a nation-wide program to promote healthier diet and lifestyle choices was to be implemented, after which time the ban on sales would be lifted and the import duty reduced to 100% or replaced by other taxes or WTOcompliant regulatory measures [18].

Trans Pacific Partnership Agreement (TPPA) The TPPA is a regional agreement currently being negotiated between eleven countries from around the Pacific Rim (Australia, Brunei, Canada, Chile, Malaysia, Mexico, New Zealand, Peru, Singapore, the United States and Vietnam). At this stage it does not include the Pacific islands but it is possible that they will become members at some stage in the future. The United States is seeking strong intellectual property provisions in this agreement that could reduce access to medicines in developing countries. The US also wants investment provisions included which will allow foreign companies to sue governments over policies and laws that reduce the value of their investments. This could present problems for public health policies such as tobacco control policy.

A closer look at the risks trade agreements pose for prevention and management of NCDs Trade agreements can affect non-communicable diseases in the Pacific islands in many different ways.

1) Increased trade can increase the supply of imported unhealthy products and decrease the demand for locally produced healthy food Trade agreements are designed to increase trade. In Pacific Island nations, increased trade has historically been associated with an increased supply of (and demand for) imported, unhealthy products [19, 20]. Increased imports can lead to reduced demand for locally produced foods. Compounding this, availability of local traditional foods can be reduced by an agricultural policy focus on export production. This policy focus is generally supported by the WTO and international donors, as well as by domestic governments’ desire to improve the Balance of Payments. In many countries, increased production of export crops has resulted in reduced production and increasing prices of traditional healthy staple crops, such as root crops [21, 22]. Increased access to export markets can lead to better quality foodstuffs being selectively channeled to the export market with negative implications for domestic price and supply with particular implications for access by poorer people. For example, sale of international fishing rights, due to limited domestic capacity for investment, has reduced availability of local fresh fish. In Micronesia and Fiji, this has contributed to fewer opportunities for local access to fish stocks and other marine resources – and also contributed to unhealthy diets due to reduced consumption of fresh fish [23, 24].

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2) Reducing tariffs can reduce the cost of unhealthy imported products. One of the main aims of trade liberalization is to reduce ‘barriers to trade’, such as tariffs and subsidies. Removing tariffs makes imported high-fat foods like mutton flaps and turkey tails cheaper. They can become cheaper than local fish or locally produced lower-fat meats, thus encouraging consumption. Another factor associated with the reduced cost of imports is apparent ‘dumping’ of agricultural products – for instance, in the Pacific this has been claimed with respect to high levels of cheap turkey tail and mutton flap imports that have undermined domestic agricultural production and increased availability of cheap fatty meat [25, 26]. In the context of significant agricultural subsidies in high income countries, local production of (often healthier) foods cannot compete [27].

3) Trade agreements can reduce the ‘policy space’ for governments to introduce policies and laws to prevent and control NCDs. Measures to address NCDs in the Pacific islands include policy interventions (on price, advertising, and other regulatory approaches) as well as health promotion strategies such as social marketing campaigns and community based programs. But the rules of trade agreements may restrict the ability of governments [19, 28] to: -

prevent the sale of unhealthy products (e.g. bans);

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regulate marketing/advertising of unhealthy products;

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control prices of unhealthy products (eg. through taxes, tariffs and duties);

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subsidise local production of healthy foods; and

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introduce food standards and product labeling.

In many cases, these sorts of policy tools (bans, advertising regulations, price controls, subsidies, food standards and product labeling) may still be used - if they are applied to all products rather than discriminating against imported products, for example.

4) Trade agreements can compromise the health system’s ability to prevent and manage NCDs, by: -

increasing the flow of health workers from poor countries to rich countries;

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making comprehensive, integrated chronic disease management programs more difficult to deliver, if privatized services are able to choose to deliver the most lucrative services and not provide others;

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increasing the price of medicines by making pharmaceutical patents easier to gain and making it more difficult for developing countries to import or manufacture generic, lower cost equivalents;

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making health care less affordable for the poor by entrenching a two-tiered health system (protected by regulation), with loss of health workers from public to private services and loss of the social solidarity needed to build a movement towards universal health cover;

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reducing government investment in health care and the funding available for NCD prevention and management.

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Can the health sector and the trade negotiators work together for win-win outcomes? The concept of policy coherence asks that health policies and trade agreements are formulated in ways which enable both trade objectives and public health objectives to be met at the same time. In 2006 the World Health Assembly adopted a resolution on trade and health which argues for ministries of health being responsible for liaising with and educating trade officials about the relationships between international trade and health, in order to ‘take advantage of the potential opportunities, and address the potential challenges that trade and trade agreements may have for health’. The resolution also urges member states to establish coordination mechanisms between ministries of finance, health and trade; to generate coherence in national trade and health policies through cross-sectoral relationships; and to ‘continue to develop capacity at national level to track and analyse the potential opportunities and challenges of trade and trade agreements for healthsector performance and health outcomes’. It highlights the need for building the capacity of member states to understand the implications of international trade and trade agreements for health and to be able to take advantage of opportunities and address the challenges. The resolution notes that collaboration with civil society organizations can be a significant avenue for such capacity building. There are two different agenda items for such health / trade collaboration which we may call: Trade compliant health promotion, and Healthy trade agreements. In developing health promotion strategies which seek to utilise pricing or other regulatory levers it makes sense for health policy officials to work closely with trade officials to ensure that any flexibilities built into existing trade commitments are fully utilised. If there are ways of regulating access to alcohol and tobacco which are fully consistent with existing commitments it makes sense to explore these. The health sector can also contribute to the design of ‘healthy trade agreements’ by ensuring that health considerations are fully taken into account. This would involve enabling provisions to support regulation for public health and ensuring that adverse consequences associated with other chapters and provisions are avoided. These kinds of negotiations require lawyers, health policy officials and trade officials who are all expert in their own fields and fully conversant with the other disciplines. Such collaboration also requires a government mandate as well as the creation of institutional mechanisms for ongoing cooperation.

Mobilising and advocacy for healthy trade There is an important technical side to trade policy making but this is not the whole story. There is also a political dimension which is about people with different interests and perspectives arguing for outcomes which are beneficial to them. There are many powerful stakeholders who benefit from the NCDs epidemic, for example, tobacco companies. They often have much at stake and can be very focused on getting the outcomes they want. In contrast, the people whose health is at stake constitute a much more diffuse collectivity, relatively unorganized, unaware and inarticulate in comparison to the industry stakeholders.

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Public health advocates need to engage vigorously in these debates, not ‘against’ the trade negotiators but contributing to the policy discourse which will shape what the trade negotiators from both (all) sides are aiming for. Such advocacy involves identifying who will be opposed and how their opposition might be managed; who would be in favour but may need to be mobilized; who are unconvinced and might need to be persuaded? Take tax and pricing policies as an example. Who needs to be persuaded? Who will oppose? How to persuade? What evidence? What mobilization? While the negotiations with the trade officials is largely a domestic and in some degree confidential process, mobilizing advocacy around the case for health needs to be thought about at the national, regional and global levels.

Conclusions Trade affects health. Health officials, and other health practitioners, have an important role to play: building the case for policy coherence; working with trade officials; and supporting advocacy towards health promoting trade agreements.

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